Citation Nr: 1702683 Decision Date: 02/01/17 Archive Date: 02/15/17 DOCKET NO. 12-29 412 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Roanoke, Virginia THE ISSUES 1. Entitlement to an increased rating for service-connected right wrist carpal tunnel syndrome, currently evaluated as 10 percent disabling. 2. Entitlement to an increased rating for service-connected left wrist carpal tunnel syndrome, currently evaluated as 10 percent disabling. 3. Entitlement to service connection for Grave's disease, also claimed as hyperthyroidism. 4. Entitlement to service connection for exercise-induced asthma. REPRESENTATION Appellant represented by: The American Legion ATTORNEY FOR THE BOARD R. Sauter, Associate Counsel INTRODUCTION The Veteran had active service from January 1998 to July 2001, with subsequent Reserves service. These matters come before the Board of Veterans' Appeals (Board) on appeal from rating decisions from the Department of Veterans Affairs (VA) Regional Office (RO) in Roanoke, Virginia. A December 2009 rating decision continued the separate 10 percent rating evaluations for right and left wrist carpal tunnel syndrome. A June 2012 rating decision denied service connection for Grave's disease and exercise-induced asthma. FINDINGS OF FACT 1. For the entire appeal period, right wrist carpal tunnel syndrome is manifested by moderate symptoms of constant pain, tingling, and numbness, without incomplete paralysis of the median nerve. 2. For the entire appeal period, left wrist carpal tunnel syndrome is manifested by moderate symptoms of constant pain, tingling, and numbness, without incomplete paralysis of the median nerve. 3. The Veteran does not have a current disability of Grave's disease. 4. The Veteran does not have a current disability of exercise-induced asthma. CONCLUSIONS OF LAW 1. The criteria for the award of a disability rating of 30 percent, but no higher, for right wrist carpal tunnel syndrome have been met. 38 U.S.C.A. §§ 1155, 5107(b) (West 2014); 38 C.F.R. §§ 4.1 -4.7, 4.120, 4.124, 4.124(a), Diagnostic Code 8599-8515 (2016). 2. The criteria for the award of a disability rating in excess of 20 percent, but no higher, for left wrist carpal tunnel syndrome have been met. 38 U.S.C.A. §§ 1155, 5107(b) (West 2014); 38 C.F.R. §§ 4.1 -4.7, 4.120, 4.124, 4.124(a), Diagnostic Code 8599-8515 (2016). 3. The criteria for service connection for Grave's disease are not met. 38 U.S.C.A. §§ 1110, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2016). 4. The criteria for service connection for exercise-induced asthma are not met. 38 U.S.C.A. §§ 1110, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2016). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist As provided by the Veterans Claims Assistance Act of 2000 (VCAA), VA has duties to notify and assist a claimant in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a). Upon receipt of a complete or substantially complete application for benefits, VA is required to inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will obtain; and (3) that the claimant is expected to provide. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b). In claims for increased rating, the VCAA requires generic notice, that is, the type of evidence needed to substantiate the claim, namely, evidence demonstrating a worsening or increase in severity of the disability and the effect that worsening has on employment, as well as general notice regarding how disability ratings and effective dates are assigned. Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009). The RO issued a preadjudicatory notice letter dated in November 2008 to the Veteran which met the VCAA notice requirements. Regarding the service connection claims, the VCAA duty to notify initially was satisfied by way of pre-adjudicatory letters the RO sent to the Veteran in November 2010 (Grave's disease) and June 2012 (exercise-induced asthma). The letters informed of the evidence required to substantiate the claim and of the respective responsibilities in obtaining this supporting evidence, including advising of how disability ratings and effective dates are assigned. Thus, the Veteran has received all required notice concerning the claims. VA also has a duty to assist a claimant in the development of a claim. This duty includes assisting in the procurement of service treatment records (STRs) and pertinent post-service treatment records (VA and private) and providing an examination when needed to assist in deciding the claim. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. The Board finds that all necessary development has been accomplished. The claims file contains the Veteran's service treatment records, VA and private medical treatment evidence, and the lay statements of the Veteran and her friends, relatives, and coworkers. The Veteran underwent VA examinations in December 2008 and July 2013 to assess carpal tunnel syndrome. Examinations for Grave's disease and exercise-induced asthma were provided in July 2013. 38 U.S.C.A. § 5103A(d)(2); 38 C.F.R. § 3.159(c)(4); McLendon v. Nicholson, 20 Vet. App. 79 (2006). The examinations are adequate because they were performed by medical professionals, and were based on a review of the record and history and symptomatology from the Veteran and a thorough examination of the Veteran. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The Veteran has not identified, and the record does not otherwise suggest, any additional existing evidence that is necessary to decide this claim that has not been obtained and that is obtainable; therefore, no further notice or assistance with this claim is required. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001). VA's duties to notify and assist with this claim have been satisfied. Increased Evaluations Disability evaluations (ratings) are determined by evaluating the extent to which a veteran's service-connected disability adversely affects his or her ability to function under the ordinary conditions of daily life, including employment, by comparing the symptomatology with the criteria set forth in the Schedule for Rating Disabilities (Rating Schedule). 38 U.S.C.A. § 1155; 38 C.F.R. §§ 4.1, 4.2, 4.10 (2016). In evaluating a disability, the Board considers the current examination reports in light of the whole recorded history to ensure that the current rating accurately reflects the severity of the condition. The Board has a duty to acknowledge and consider all regulations that are potentially applicable. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). The medical as well as industrial history is to be considered, and a full description of the effects of the disability upon ordinary activity is also required. 38 C.F.R. §§ 4.1, 4.2, 4.10. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. See 38 C.F.R. § 4.7. Reasonable doubt regarding the degree of disability will be resolved in the veteran's favor. 38 C.F.R. § 4.3. In deciding this appeal, the Board has considered whether separate ratings for different periods of time, based on the facts found, are warranted, a practice of assigning ratings referred to as "staging the ratings." See Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2008). Lay assertions may serve to support a claim for service connection by establishing the occurrence of observable events or the presence of disability or symptoms of disability subject to lay observation. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); see also Buchanan v. Nicholson, 451 F.3d 1331, 1336 (Fed. Cir. 2006) (addressing lay evidence as potentially competent to support presence of disability even where not corroborated by contemporaneous medical evidence). The Federal Circuit has clarified that lay evidence can be competent and sufficient to establish a diagnosis or etiology when (1) a lay person is competent to identify a medical condition; (2) the lay person is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). The Board must assess the credibility and weight of evidence. Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997), cert. denied, 523 U.S. 1046 (1998); Wensch v. Principi, 15 Vet. App. 362, 367 (2001). The standard of proof to be applied in decisions on claims for veterans' benefits is set forth at 38 U.S.C.A. § 5107. A claimant is entitled to the benefit of the doubt when there is an approximate balance of positive and negative evidence. See 38 C.F.R. § 3.102. When a claimant seeks benefits and the evidence is in relative equipoise, the claimant prevails. The preponderance of the evidence must be against the claim for benefits to be denied. See Alemany v. Brown, 9 Vet. App. 518 (1996). The Board has reviewed all of the evidence in the Veteran's claims file, with an emphasis on the evidence relevant to the appeal. Although the Board has an obligation to provide reasons and bases supporting its decision, there is no need to discuss, in detail, every piece of evidence of record. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (holding that VA must review the entire record, but does not have to discuss each piece of evidence). Hence, the Board will summarize the relevant evidence where appropriate and the Board's analysis below will focus specifically on what the evidence shows, or fails to show, as to the appeal. Increased Rating for Right and Left Wrist Carpal Tunnel Syndrome The Veteran is in receipt of separate 10 percent ratings for her right and left wrist carpal tunnel syndrome under Diagnostic Code 8599-8515. She contends that higher ratings are warranted based on her complaints of pain, numbness, tingling, and activity limitations. Considering the lay and medical evidence of record, the Board finds that increased ratings of 30 percent for the right (dominant) wrist, and 20 percent for the left wrist are warranted. Generally, hyphenated diagnostic codes are used when an unlisted disability is at issue. See 38 C.F.R. § 4.27. Use of the second diagnostic code helps provide further detail regarding the origins of the unlisted disability, the bodily functions affected, the symptomatology, and anatomical location. Id.; see Tropf v. Nicholson, 20 Vet. App. 317, 321 (2006). Additionally, the diagnostic code following the hyphen is the diagnostic code by which the disability is evaluated. Id. Under Diagnostic Code 8515, a 10 percent evaluation is assigned for mild incomplete paralysis of the median nerve of the major or minor hand. A 30 percent evaluation is assigned for moderate incomplete paralysis of the median nerve of the major hand; a 20 percent rating is assigned for the minor hand. A 50 percent evaluation is assigned for severe incomplete paralysis of the median nerve of the major hand; a 40 percent rating is assigned for the minor hand. Finally, a 70 percent evaluation is assigned for complete paralysis of the median nerve of the major hand, with the hand inclined to the ulnar side, the index and middle fingers more extended than normally, considerable atrophy of the muscles of the thenar eminence, the thumb in the plane of the hand (ape hand); pronation incomplete and defective, absence of flexion of index finger and feeble flexion of middle finger, cannot make a fist, index and middle fingers remain extended; cannot flex distal phalanx of thumb, defective opposition and abduction of the thumb, at right angles to palm; flexion of the wrist weakened; pain with trophic disturbances; a 60 percent rating is assigned for the minor hand. 38 C.F.R. § 4.124a, Diagnostic Code 8515 (2016). The term "incomplete paralysis" with this and other peripheral nerve injuries indicates a degree of lost or impaired function substantially less than the type pictured for complete paralysis given with each nerve, whether due to varied level of the nerve lesion or to partial regeneration. When the involvement is wholly sensory, the rating should be of the mild, or at most, the moderate degree. 38 C.F.R. § 4.124a. Words such as "mild," "moderate," "moderately severe" and "severe" are not defined in the Rating Schedule. Rather than applying a mechanical formula, the Board must evaluate all of the evidence to the end that its decisions are "equitable and just." 38 C.F.R. 4.6. Use of terminology such as "severe" by VA examiners and others, although evidence to be considered by the Board, is not dispositive of an issue. All evidence must be evaluated in arriving at a decision regarding an increased rating. 38 C.F.R. §§ 4.2, 4.6. Upon VA examination in December 2008, the diagnosis was bilateral carpal tunnel syndrome with numbness and tingling. The effect of the condition on the Veteran's ability to perform activities of daily living is that it causes her to fatigue easily. The examiner observed that the Veteran can tie her shoelaces, fasten buttons, and pick up a piece of paper and tear it without difficulty. The Veteran submitted several lay statements dated in December 2008 in support of her claim. K.R., a friend and professional colleague, states that she has observed that the Veteran experiences severe pain while pushing a stroller or grocery cart, and that the pain prevents her from doing these activities for very long. K.R. states that the Veteran asks for K.R.'s assistance in washing, combing, and braiding the Veteran's children's hair. K.R. has also observed the Veteran having difficultly doing yard work, and styling her own hair. Finally, K.R. observed that the Veteran wears wrist braces at work to alleviate pain during typing and writing, which seem to slow her production of work. A coworker, C.R., states that she has observed the Veteran working with her wrist braces, which seems to prevent her from doing her work at a normal speed. C.R. has also observed the Veteran having difficulty holding a water bottle. C.R. speculates that wrist pain "hinders [the Veteran] from doing the things that she enjoys to do." Another coworker, K.W., observes that the Veteran's braces do not seem to relieve her pain, and that she is limited in performing job duties such as typing, filing, shredding, and answering the telephone. The Veteran's mother, S.K.B., observes that the Veteran's pain limits her ability to braid her children's' hair and do chores around the house. The Veteran's spouse, K.W. observes that the Veteran's wrist pain prevents her from doing activities that she enjoys. K.W. notes that the Veteran experiences trouble sleeping due to her wrist pain, and often needs to sit up and shake her arms to relieve the disturbing sensation. K.W. states that, due to his deployment, the Veteran is usually responsible for all of the household chores, and she is unable to complete certain tasks, such as mowing the lawn, due to her wrist pain. K.W. notes that the Veteran has difficultly styling their children's hair, and that she is sometimes unable to read a book due to the pain caused by keeping her hands in one position. The Veteran was provided a January 2013 decision review officer hearing at the RO. The Veteran reported constant pain due to her carpal tunnel syndrome. She reported that, although she is able to perform activities of daily living such as cooking, washing her hair, pushing a grocery cart, carrying items, and performing her basic job functions, she is limited by constant pain. She treats her pain with over the counter pain medication, and wears wrist braces constantly. A January 2013 hospitalization record shows that the Veteran was admitted for right carpal tunnel release surgery and discharged two days later. Upon VA examination in July 2013, the diagnosis was bilateral carpal tunnel syndrome, with severe constant pain, paresthesias and numbness on the left, and with no pain and moderate paresthesias and numbness on the right. Strength testing, reflex testing, and sensory testing were within normal limits. No complete or incomplete paralysis was found. No trophic changes were found. The Veteran is right hand dominant. A July 2013 VA treatment record notes pain in the fingers of the right hand due to carpal tunnel syndrome. The Veteran uses a wrist brace and has occasional flare ups of pain following surgical release of ligament for carpal tunnel. An August 2013 VA treatment record shows that she was fitted with a wrist brace. The Board finds that the Veteran's symptoms more nearly approximate the next higher rating evaluations. The medical and lay evidence reflects that she has constant pain, numbness, and tingling, which has a moderate impact on her ability to work and participate in activities of daily living. The lay statements of record demonstrate that she is limited in both professional and personal activities, in that she is unable to complete tasks in a reasonable amount of time. The medical evidence of record shows that the Veteran is right hand dominant. The highly probative clinical evaluations generally reflect sensory impairment and do not show additional symptomatology, such as skin/trophic changes, impaired reflexes, or periods of complete or incomplete paralysis. The rating criteria limit the findings of severity to moderate for sensory disturbance symptoms. Here, the clinical evidence as well as the lay testimony demonstrates moderate symptomology. 38 C.F.R. § 4.124 (a). Consequently, increased ratings of 30 percent for the dominant right hand, and 20 percent for the left hand are warranted. Id. The Board finds that higher ratings of 40 percent for the right hand and 30 percent for the left hand are not warranted. Neurological symptoms consisting of sensory disturbances cannot be assessed as posing more than moderate incomplete paralysis. 38 C.F.R. § 4.124a. The clinical evidence detailed above shows that the Veteran's carpal tunnel symptoms generally consisted of moderate sensory disturbances. The clinical evidence weighs against findings of impaired motor function, muscle atrophy, or skin changes in either wrist. The Board considers the clinical evidence to be most probative in determining whether additional symptoms such as muscle atrophy, trophic changes, and weakness, among others are present. Caluza v. Brown, 7 Vet. App. 498, 510-511 (1995), aff'd, 78 F.3d 604 (Fed. Cir. 1996) (per curiam) (table) see Madden v. Brown, 125 F. 3d 1447, 1481 (Fed. Cir. 1997); (VA adjudicators may properly consider internal inconsistency, facial plausibility and consistency with other evidence when weighing evidence). This is because the clinical findings were reported by unbiased medical professionals. Id. Given the limitations for peripheral neuropathy ratings based primarily on sensory disturbances, a finding of severe partial paralysis for peripheral neuropathy is not warranted. Id.; 38 C.F.R. § 4.124a, Diagnostic Codes 8599-8515. To the extent that the Veteran seeks ratings higher than 30 percent for right wrist carpal tunnel syndrome, and 20 percent for left wrist carpal tunnel syndrome, the preponderance of the evidence is against the claim. Therefore, the benefit of the doubt doctrine does not apply, and the claims must be denied. 38 U.S.C.A. §5107 (b); 38 C.F.R. § 3.102. Extraschedular The Board has considered whether referral for extraschedular consideration is warranted. An extraschedular disability rating is warranted based upon a finding that the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization that would render impractical the application of the regular schedular standards. 38 C.F.R. § 3.321(b)(1) (2016); see Fanning v. Brown, 4 Vet. App. 225, 229 (1993). Under Thun v. Peake, 22 Vet App 111 (2008), there is a three-step inquiry for determining whether a veteran is entitled to an extraschedular rating. First, the Board must determine whether the evidence presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Second, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, the Board must determine whether the claimant's disability picture exhibits other related factors such as those provided by the regulation as "governing norms." Third, if the rating schedule is inadequate to evaluate a veteran's disability picture and that picture has attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the VA Under Secretary for Benefits or the Director of the Compensation Service to determine whether the veteran's disability picture requires the assignment of an extraschedular rating. Turning to the first step of the extraschedular analysis, the Board finds that the symptomatology and impairment caused by the Veteran's bilateral carpel tunnel syndrome is specifically contemplated by the schedular rating criteria, and no referral for extraschedular consideration is required. The schedular rating criteria specifically provide for disability ratings based on a combination of history and clinical findings. Considering the lay and medical evidence, the Veteran's bilateral carpel tunnel syndrome has manifested in symptoms that are either explicitly part of the schedular rating criteria or are "like or similar to" those symptoms and impairment explicitly listed in the schedular rating criteria. Mauerhan, 16 Vet. App. at 443. The schedule is intended to compensate for average impairments in earning capacity resulting from service-connected disability in civil occupations. 38 U.S.C.A. § 1155. "Generally, the degrees of disability specified [in the rating schedule] are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability." 38 C.F.R. § 4.1. The problems reported by the Veteran are specifically contemplated by the criteria discussed above, including the effect on her daily life. Additionally, she has not alleged or indicated that the collective impact or combined effect of more than one service-connected disability presents an exceptional or unusual disability picture to render inadequate the schedular rating criteria. See Johnson v. McDonald, 762 F.3d 1362 (Fed. Cir. 2014). Thus, the Board finds that the criteria for submission for assignment of an extraschedular rating pursuant to 38 C.F.R. § 3.321(b)(1) are not met. See Bagwell v. Brown, 9 Vet. App. 337 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). TDIU In Rice v. Shinseki, 22 Vet. App. 447 (2009), the United States Court of Appeals for Veterans Claims held that a claim for a total rating based on unemployability due to service-connected disability (TDIU), either expressly raised by the Veteran or reasonably raised by the record involves an attempt to obtain an appropriate rating for a disability and is part of the claim for an increased rating. In this case, the Veteran has not specifically argued, and the record does not otherwise reflect, that her disabilities render her totally unemployable. The record reflects that she is currently employed. Accordingly, a claim for TDIU has not been raised. Service Connection Legal Criteria Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active military, naval or air service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303(a). Service connection may be granted for any disease diagnosed after discharge when all of the evidence, including that pertinent to service, establishes that the disease was incurred in active service. 38 C.F.R. § 3.303(d). Service connection may also be granted for a disability that is proximately due to or the result of a service-connected disability. See 38 C.F.R. § 3.310 (a). When service connection is thus established for a secondary condition, the secondary condition shall be considered a part of the original condition. See 38 C.F.R. § 3.310 (a); Harder v. Brown, 5 Vet. App. 183, 187 (1993). To prevail on the theory of secondary service causation, generally, the record must show (1) medical evidence of a current disability, (2) a service-connected disability, and (3) medical nexus evidence establishing a connection between the current disability and the service-connected disability. Wallin v. West, 11 Vet. App. 509, 512 (1998); Reiber v. Brown, 7 Vet. App. 513, 516-17 (1995). Congress has specifically limited entitlement for service-connected disease or injury to cases where such incidents have resulted in disability. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992); Rabideau v. Derwinski, 2 Vet. App. 141 (1992); Gilpin v. Brown, 155 F.3d 1353 (Fed. Cir. 1998). A current disability means a disability shown by competent evidence to exist. Chelte v. Brown, 10 Vet. App. 268 (1997). The most fundamental requirement for any claim for service connection is current disability. See Degmetich v. Brown, 104 F.3d 1328 (1997) (indicating VA compensation only may be awarded to an applicant who has disability existing on the date of application, not for past disability); but see McClain v. Nicholson, 21 Vet. App. 319 (2007) (further clarifying that this requirement of current disability is satisfied when the claimant has the disability at the time the claim for VA disability compensation is filed or during the pendency of the claim and that a claimant may be granted service connection even though the disability resolves prior to VA's adjudication of the claim). Service Connection for Grave's Disease and Exercise-Induced Asthma The Veteran contends that she is entitled to service connection for Grave's disease and exercise-induced asthma. As the weight of the evidence does not demonstrate a diagnosis of either condition at any time during the appeal period, the Board finds that service connection is not warranted. The medical evidence reflects that she was diagnosed with hyperthyroidism/Grave's disease by a private physician in August 2004. She was prescribed a medication to suppress the thyroid function. A VA treatment record of March 2009 noted her prior diagnosis, stating that, "she was treated with about one year with medication for overactive thyroid in 2003 but was told everything was OK after that and the medication was stopped." The examiner observed "depressed [thyroid stimulating hormone (TSH)]; no symptomatic complaints." The thyroid condition was assessed as being in remission, and periodic clinical and laboratory followup was recommended. Another VA treatment record of March 2009 noted "mild or low normal TSH" and "mixed symptoms that are not clearly specific for thyroid disease." The examiner did not recommend treatment based on these findings. A VA treatment note of September 2009 remarks that the author "explained that the [Veteran] still has Grave's disease but I consider that she is still in remission and her most recent [thyroid function tests] done last week were all in the normal range." A December 2010 VA treatment record notes that the Veteran's Grave's disease is in remission. A VA thyroid function test of May 2011 was reported as normal. At the January 2013 decision review officer hearing at the RO, the Veteran reported that she is not currently taking medication for her thyroid condition, but has periodic blood tests to check the levels of her thyroid hormones. A July 2013 VA examiner acknowledged the Veteran's prior diagnosis, but opined that there is not current diagnosis of a thyroid disorder, because the condition has resolved. A VA thyroid function test of July 2013 was reported as normal. Regarding her claimed condition of exercise-induced asthma, service treatment records show that the Veteran complained of breathing problems during her pregnancy in March 2001. There was no assessment of any respiratory condition, and no follow-up testing was ordered regarding her complaints. VA treatment records of February 2009 note that the Veteran has no history of asthma. At the January 2013 decision review officer hearing at the RO, the Veteran recalls complaining of breathing problems upon separation, when she was pregnant. She stated that she sometimes experiences problems breathing while exercising, "depending on the intensity of the exercise." She reported that she experiences breathing problems when she is jogging or walking in cold weather. She testified that she has not received a diagnosis of asthma from a doctor, and that she does not take medication or seek treatment for asthma or her reported breathing problems. She underwent a VA examination in July 2013 to assess her claimed asthma. Pulmonary function testing was within normal limits, and the examiner noted that there is no diagnosis of asthma. The VA examinations are highly probative medical evidence. The VA examiners were informed of the relevant evidence, relied on accurate facts, and gave fully articulated opinions that were supported by sound reasoning. Hernandez-Toyens v. West, 11 Vet. App. 379, 382 (1998); see also Claiborne v. Nicholson, 19 Vet. App. 181, 186 (2005). After considering the above the Board finds that the preponderance of the evidence is against the claims, as the preponderance of the evidence fails to demonstrate a current disability of Grave's disease or exercise-induced asthma. To that end, the evidence reflects that her Grave's disease, diagnosed in 2004, has been in remission and has not been present at any time during the period on appeal. The evidence further reflects that she has never been diagnosed with exercise-induced asthma. A threshold requirement for the granting of service connection is evidence of a current disability. In the absence of evidence of a current disability there can be no valid claim. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). The Board carefully considered the Veteran's lay statements. Lay statements may be competent to support a claim for service connection by supporting the occurrence of lay-observable events or the presence of disability or symptoms of disability subject to lay observation. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); see also Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006) (addressing lay evidence as potentially competent to support the presence of disability even where not corroborated by contemporaneous medical evidence). However, diagnosing a thyroid or respiratory disorder goes beyond a simple and immediately observable cause-and-effect relationship and may require evaluation of imaging studies, clinical findings, and pulmonary function testing. The Veteran has not demonstrated that she has the requisite medical knowledge to determine whether she has a currently diagnosed thyroid or respiratory disorder. Thus, whether the Veteran has a current thyroid or respiratory disorder requires specialized training for a determination and is not susceptible of lay opinion. The Veteran's statements alone cannot be accepted as competent medical evidence. Because the criteria for current disability have not been met, the Board finds that a preponderance of the evidence is against the Veteran's claims for service connection for Grave's disease and exercise-induced asthma, the benefit of the doubt doctrine is not for application, and the claims must be denied. See 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102; Brammer at 225 (1992) ("Congress specifically limits entitlement to service-connected disease or injury to cases where such incidents have resulted in a disability"). ORDER Entitlement to an increased rating of 30 percent, but no higher, for service-connected right wrist carpal tunnel syndrome is granted. Entitlement to an increased rating of 20 percent, but no higher, for service-connected left wrist carpal tunnel syndrome is granted. Service connection for Grave's disease, also claimed as hyperthyroidism, is denied. Service connection for exercise-induced asthma is denied. ____________________________________________ T. D. JONES Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs